Date

YYYY

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Phone Number

(###)

###

####

How did you hear about us?

Friend/Family

Instagram

Facebook

Google Search

Bronze Glow Client

BodyPlex

Other

Have you ever had a filler treatment before?

Yes

If "yes", when was service received?

YYYY

If "yes", what type of service was received?

Have you ever had a skin reaction during or following a filler procedure or filler product?

Yes

If "yes", please specify:

Do you have any skin or food allergies?

If "yes" please describe in detail the reaction and the allergy source

Which of the following best describes your skin type?

Have you received any of the following treatments within the past 14 days? (check all that apply)

laser

botox

cosmetic fillers

facial tattoo or microblading

miccroneedling/ vivace

none

Have you been diagnosed with advanced diabetes?

Yes

Please list all medications (including supplements) you are taking currently. If none write N/A

Are you pregnant or trying to become pregnant?

Yes

Any menopause problems?

Yes

Are you undergoing any hormone replacement therapy?

Yes

Do you experience claustrophobia?

Select

Do you drink alcohol on a regular basis?

Select

Do you smoke tabacco?

Select

Have you experienced Botox, Restylane or Collagen injections in the desired treated area(s) within the past six weeks?

Yes

Please initial that you understand the following: If you have received cosmetic fillers or injectables within the last 6 weeks and do not reschedule your filler appointment, you will be unable to receive fillers and you will not be refunded for the service amount. Your fillers/injectables will not be settled before this time! This is important!

Please initial that you assume all risk and release all liability when receiving a hyaluronic lip filler service?

Do you understand that failure to answer all questions of this form completely and truthfully can prevent services from being redered??

Please initial that you understand the following: If you do not cancel and or reschedule your appointment within 24 hours of your appointment time you will be charged a non-refundable $100 fee for the time slot that was reserved especially for you?

Please initial that you understand the following: If you fail to call or show for your appointment, you will be charged the full service amount without refeund.

Photo Release

Do you consent to before and after photos/videos if applicable?

Yes

Late and Early Appointment Policy:

The time you book your appointment is especially reserved for you. Please note, the service being rendered begins at the time of appointment. Depending on service being rendered, The service time slot includes check in, check out and dress time. If you are early for your appointment and can be seen at arrival, your service time begins when brought to treatment room. If you are late for your appointment, your service time begins at your originally scheduled time. Please initial below acknowledging the above policy.

Please initial that you understand that all card transactions will be charged a 3% service fee

Client Consent Form

Please understand that due to mandatory preparations to accommodate allergies that client consent forms must be filled out four hours prior to scheduled appointment time. Failure to do so will result in appointment being rescheduled and a charge of a $50 non-refundable scheduling fee. Please initial that you understand the above client consent policy.

Right to refuse service

Please understand that Nourished Esthetics has the right to refuse service to anyone. Please initial that you understand.

Use of legal name for any paperwork

It is imperative that any paperwork that is filled out for Nourished Esthetics is filled out with your legal name that matches your driver's license or any government issued id. Please initial that you understand the above Use of legal name policy.

AGREEMENT:

As a patient, you have requested my administration of a stabilized hyaluronic acid used in the correction of moderate to severe facial wrinkles and folds. All medical and cosmetic procedures carry risks and may cause complications. The purpose of this document is to make you familiar with the procedure and it’s risks in advance. This way, you can decide whether or not to go forward with the process. THE PROCESS: *This product is administered via a syringe, or a special pen, into the areas of the face. *Numbing medicine can be used to reduce the discomfort. *The treatment site(s) is washed first with an antiseptic (cleansing) solution. *Hyaluronic acid is a clear transparent gel that will be injected under your skin into the tissue of your face. *The depth of the injection(s) will depend on the depth of the wrinkle(s) and its location(s). *Multiple injections might be May depending on the location or depth of the wrinkle. *Following each injection, the service provider should gently massage the correction side, to conform to the contour of the surrounding tissues. *If the treated area is swollen directly after the injection, you can apply ice on the site for a short period. After the first treatment, additional treatments of hyaluronic acid may be necessary to achieve the desired level of correction. *Periodic touchup injections help sustain the desired level of correction. HAF corrects an average of 6 to 12 months. Some products made last up to 18 months. This effect varies depending on general health, dietary and smoking habits, the type of skin, areas, injected, and the amount and type of product injected. The duration may be shorter in clients who have a history of smoking, have sun damage, those who continue to suntan, those who undergo heat modalities as Radio-frequency or Ultrasound. Clients who exercise intensively may also have a shorter duration of effect. RISKS/DISCOMFORT: The service provider has discuss with me, and I clearly understand that, during and after the injection, there are some potential side effects. Which include and may not be limited to: *Inflammatory reactions, such as redness, edema(swelling) and or erythema. *Stinging, *Pain pressure. These reactions may last up to one week or more, depending on my own natural healing. Delayed hypersensitivity reactions, swelling, or nodules, may develop at the injection site, even up to six months or longer after the procedure, very rare cases of discoloration of the injection site have been reported. *Persistence of inflammatory reactions for more than one week or the development of any other side effect must be reported to the physician as soon as possible. Increase of bruising or bleeding at the injection site, if using a substance, such as Ibuprofen(Advil). Some visible lumps may occur temporarily following the injection. Some patients may experience additional swelling or tenderness at the injection site, and on rare occasions, pustules my form. Some patients may notice temporary, numbness or tingling in the area treated that usually will last less than a month to one year. Initials below:

Do you have severe allergies?

Yes

Are you breastfeeding?

Yes

Are you sensitive to hyaluronic acid?

Yes

I tend to develop hypertrophic scarring

Yes

I am receiving immunotherapy treatments.

Yes

OTHER CONSIDERATIONS:

Patients who have autoimmune conditions or are significantly inflammatory, have a higher chance of inflammatory reactions. Treatment with HAF must be made on a case-by-case bases, with a full understanding of the risks. As with all injections, this procedure carries the risk of infection. The syringe is sterile, and standard precautions associated with injectable materials have been taken. If you are considering laser, treatment, chemical, skin peeling, or any other procedures, based on a scan response after HAS treatment, or the skin has not been healed completely from a previous procedure, there is a possible risk of an inflammatory reaction at the implant site. Most patients are pleased with the results of HAF’s; however, like any cosmetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear, completely or that you will not require additional treatments to achieve the results you seek. While the effects of HAF one use can last longer than other comparable treatments, the procedure is still temporary. Additional treatments will be required. Periodically, generally within six months to one year, involving additional injections for the effect to continue. After treatment, you should minimize exposure of the treated area to excessive sun or UV lamp, exposure, and extreme cold weather. Initials below:

ALTERNATIVES:

This is a voluntary cosmetic procedure. No treatment is necessary or required. Other alternative treatments, which vary in sensitivity, effect, and duration include: animal-derived collagen filler products, dermal fillers derived from the patient’s own fat tissues, synthetic plastic permanent implants, or bacterial toxins that can weaken muscles. Initials below:

CONSENT:

My consent and authorization for this procedure are strictly voluntary. By signing this informed consent form, I hear by grant authority to the service provider to perform filler therapy/injections using hyaluronic filler for the treatment of my condition. The nature and purpose of this procedure, with possible alternative methods of treatment, as well as the complications, have been fully explain to my satisfaction. No guarantee has been given by anyone asked to the results that may be obtained by this treatment. I have read this informed consent, and certify that I understand its contents in full. I have had enough time to consider the information and feel that I am sufficiently advised to consent to this procedure. I understand that any treatment provided may or may not meet my expectations. I understand, and agree that there is no compensation or refund. I am aware of the risks and complications of this procedure, including, but not limited to, bruising, swelling, asymmetry, and blindness. Initials below:

Thank you for scheduling your appointment!